Introduction

The goal of any reconstruction is to restore to normal, or as close to normal, form and function. This could only be completely achieved by replantation or in the future transplantation. All of our current reconstructive methods will always fall short of the ideal due to specific tissue characteristics. Hence the need for secondary, tertiary, or in fact multiple revisional procedures to achieve the best possible functional and aesthetic result. Indeed, the meaning of the word plastic, which is derived from the Greek plastikos, means to make or mold.

This chapter will address the principles and techniques utilized to enhance the final result of the initial primary reconstructive procedure. The sequence of reconstruction and timing in the application of these different techniques should be guided by basic principles. A well-thought-out reconstructive path is needed from the start so as not to “burn any bridges.” Secondary facial reconstructions can be broadly separated into: (1) those that were part of the initial reconstructive plan; and (2) those that were unplanned and which may present to a different surgeon as a challenging case.

Historical perspective

Much has been written about the principles of reconstruction by the giants and early pioneers of plastic surgery, including Tagliacozzi, Paré, Gillies, and Millard, among others. The aims are always to restore to normal. Over the last century many techniques of increasing sophistication have been described. Our armamentarium continues to expand, so that today the reconstructive surgeon has many options to consider for achieving the best possible result. To maximize the end result in complex reconstruction, it is in fact not uncommon to utilize every rung of the reconstructive ladder, or as Bennett and Choudhary have described, the “reconstructive elevator,” which takes the reconstructive surgeon directly to the best method of reconstruction based on the patient’s needs and within the surgeon’s realm of experiences.¹

Basic science/disease process

Secondary facial reconstruction assumes a previous operative procedure, the cause of which in the head and neck may have a wide range of etiologies, from congenital malformations to various types of trauma, including burns, ballistic injuries, motor vehicle accidents, and animal bites. Tumors involving both bone and soft tissues, and infections may also have been the culprit. Each one of these etiologies has its own unique consequences.

Tissues may have been lost, displaced, or distorted. Both bone and soft tissues may have been involved. A common feature of all these etiologies is that along the way wounds were created and treated. These may have been simple and superficial but more likely, deep and complex. Healing may have been facilitated by primary or secondary closure, or involved a prior operative procedure utilizing tissue locally or afar. It should be remembered that there is renewed swelling and scarring at each interface, and that this occurs with each operative procedure, which in turn makes the outcome after each procedure somewhat unpredictable. It is usual and safe practice to allow the patient and the involved tissue to heal, the swelling to subside, and the scarring to mature before embarking on secondary and tertiary reoperative procedures.

Diagnosis/patient presentation

An accurate diagnosis of the deformity and an appraisal of the missing parts are essential. The deformity is compared with what is considered to be the “perceived normal.” If the deficit is unilateral, the best guide is a comparison with the opposite side. With more extensive defects where both sides are involved, a consideration of baseline appearance as seen on an old photograph may serve as a guide to reconstruction. However, realistic goals must be set from the start as to what might be achievable with reconstruction.

An evaluation for secondary facial reconstruction begins with a thorough investigation into the history of the patient, in particular the operations and flaps that were previously utilized, paying close attention to the remaining donor vessels in the head and neck.² Next, an accurate diagnosis of the missing parts has to be made. While it is generally obvious what the missing parts are for a primary reconstruction that immediately follows extirpation, it is less obvious in secondary reconstructions where tissues have been pulled closed or healed secondarily. It takes an astute plastic surgeon to visualize what constitutes adequate contracture release and the resulting defect. This attention to making the correct comprehensive diagnosis is especially important when evaluating a patient whose primary reconstruction was performed elsewhere. Subsequent revisions are individualized and dictated by the area and underlying cause that required reconstruction. Therefore, a surgeon who specializes in secondary facial reconstructions needs to be well versed in all rungs of the reconstructive ladder, especially when many first-line options have already been utilized.